FORM 131. ADOPTION PETITION STATE OF VERMONT DISTRICT OF ______________, SS PROBATE COURT DOCKET NO. ______________ IN RE THE ADOPTION OF ______________, OF ____________________________________ ADOPTION PETITION 15A V.S.A. § 3-404 Part I. The undersigned petitioner(s) represent that: 1. The person to be adopted is: Name: ____________________________________, Place of birth: ________________ Date of birth: _____________, Time of birth: _______________________________ Sex: _____________, To be known as: ________________________________________ Child has resided with petitioner(s) since: ________________________________ Child [ ] is [ ] is not an Indian child as defined by Indian Child Welfare Act. 2. The petitioner(s) are: Name: ____________________________________, Maiden name: _________________ Date of birth: _________________, Place of birth: ______________________________ Mailing address: _______________________________________________________________________ _______________________________________________________________________ Town and state of residence: _______________________________________________ For how long? ___________________________________________________________ Occupation: _______________________________, Approximate income: __________ Current marital status: ____________________________, Is divorce pending? _______ If married, has spouse been judicially determined to be incompetent? _______________________________________________________________________ Relationship to adoptee: ___________________________________________________ Date of most recent favorable preplacement evaluation: __________________________ Date, court and disposition of any previous petition to adopt: ______________________ _______________________________________________________________________ _______________________________________________________________________ Name: ____________________________________, Maiden name: ________________ Date of birth: _________________, Place of birth: ______________________________ Mailing address: _______________________________________________________________________ _______________________________________________________________________ Town and state of residence: _______________________________________________ For how long? ___________________________________________________________ Occupation: _______________________________, Approximate income: __________ Current marital status: ____________________________, Is divorce pending? _______ 10/04 SML American LegalNet, Inc. www.FormsWorkflow.com 3. The petitioners acquired physical custody of the minor on: _______________ If the child is not in the physical custody of the petitioners, explain the reason and the date and manner in which the petitioners intend to obtain physical custody: ________________________________________________________________________ ________________________________________________________________________ 4. If the child was born out of wedlock, have the parents intermarried? [ ] Yes [ ] No If the child's parents are divorced, custody was awarded to ________________________ 5. The name and address of the person or agency who placed the child with the petitioners is: ________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ If not an agency, the relationship of the person who placed the child with the petitioners is: ___________________________________________________________________ 6. The description and approximate value of known property of the minor is: ________________________________________________________________________ ________________________________________________________________________ 7. The petitioner is aware that the following court orders are in effect or pending regarding the child: Child support: ___________________________________________________________ Custody: ________________________________________________________________ Visitation or contact: _____________________________________________________ 8. The petitioner(s) have completed the list of interested persons in Part I and have attached or explained in an attached affidavit the absence of the documents listed in Part III. 9. Any law governing interstate or intercountry adoption was complied with, if applicable. 10. The petitioners have the facilities and resources to provide for the care and support of the child and request that they be permitted to adopt the child. In addition, the following relief is sought: ________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Part II. Persons Interested in Adoption Proceeding The undersigned petitioner(s) represents that the following is a list of persons interested in the adoption of the above-named child as far as is known to me: 1. Mother's name: ___________________________________________________________ Mailing address: __________________________________________________________ ____________________________________________________________ Town of residence: ________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 2. Name of husband of the mother, if the child was born during the marriage or within 300 days after its termination: _________________________________________________ Mailing address: __________________________________________________________ Town of residence: ________________________________________________________ 3. Name of biological father identified by the mother: ______________________________ Mailing address: __________________________________________________________ ________________________________________________________________________ Town of residence: ________________________________________________________ 4. Name of any other man who was not married to the mother at the time of the child's birth, has acknowledged paternity and has demonstrated a parenting relationship with the child, including financial: _______________________________________________________ Mailing address: _________________________________________________________ _______________________________________________________________________ Town of residence: ________________________________________________________ 5. Name of the child's legal guardian: _________________________________________ Mailing address: ________________________________________________________ _____________________________________________________________________ Town of residence: ________________________________________________________ Part III. The following documents are attached to the petition: A. Originals or certified copies of: ________ Child's birth certificate or other record of date and place of birth: ________ Any consent, relinquishment, order terminating parental rights or disclaimer of parental interest that have been executed; ________ Written certification required of person before whom the consent or relinquishment was executed; ________ Each parent or former parent's marriage certificate, decree of divorce, annulment or dissolution, or agreement of legal separation; ________ Any court order determining the former parent's incompetence; ________ Any existing court order or petition in a pending proceeding concerning custody of, or visitation or communication with, the child; ________ Petitioner's marriage certificate, decree of divorce, annulment or agreement of legal separation; ________ Any court order determining that the spouse of the petitioner is incompetent. B. Copies of: ________ Birth certificates of petitioners; ________ Preplacement evaluation on the petitioner(s); ________ Postplacement evaluation; ________ Report on the child and family's background information required by § 2-105; ________ Any agreement with a public agency for adoption subsidy; ________ Any collateral agreement between the petitioner and parent or guardian or any agency; ________ Any request for nondisclosure signed by the parent or former parent. C. If an agency placed the child for adoption, a verified statement from the agency is required by § 3-305(a)(10). American LegalNet, Inc. www.FormsWorkflow.com Part IV. Affidavit of Unavailable Information: I, ________________________________________, after first being sworn, state that I am unable to provide the following information in Parts I, II or III: _____________________ ______________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ because the information is not known to me or not available to me after reasonable attempts to get it. Dated at __________________, this ________ day of _________________, _____. ___________________________________________________, Petitioner ___________________________________________________, Petitioner Subscribed and sworn to this ________ day of ________, _____. before me, _______________________________________________, Notary Public Subscribed and sworn to this ________ day of ________, _____. before me, ______________________________________________________, Notary Public American LegalNet, Inc. www.FormsWorkflow.com